caring for patients with spinal cord injuries...cal spine and spinal cord injury recommend...

18 American Nurse Today Volume 11, Number 5 www.AmericanNurseToday.com

SPINAL CORD INJURIES (SCIs) area significant cause of disability, withprofound—and in many cases dev-astating—consequences. Accordingto recent data, about 12,000 SCIsoccur annually in the United States,and up to 250,000 Americans areliving with SCIs. Most victims areaged 16 to 30; more than 80% aremales. In both genders, motor vehi-cle accidents, falls, and gunshotwounds account for most SCIs; inpersons aged 65 and older, falls arethe leading cause. The Centers forDisease Control and Prevention esti-mates that SCI-related medical costsamount to about $9.7 billion eachyear. (See Serious and deadly com-plications of SCI.)

Most SCIs result from direct trau-ma to the vertebral column, affect-ing the spinal cord’s ability to sendand receive messages to and fromthe brain. The disruption impairsthe systems that control sensory,motor, and autonomic functions be-low the injury level.

This article differentiates thetypes of SCIs and describes clinicaland diagnostic evaluation, treat-ment, and nursing care for patientswith SCIs. It assumes readers have abasic understanding of spinal cordanatomy and physiology.

Types of SCIsA complete SCI causes total loss ofall motor and sensory function be-low the injury level, including thelowest sacral segments. Completecord transection is rare. Functionloss usually stems from a contusionor compromised blood flow to theinjured part of the cord, as from

subluxation and hyperflexion or ex-tension injury.

With an incomplete SCI, patientsretain some level of sensory func-tion, motor function, or both belowthe injury level. They may be ableto move one arm or leg more thanthe other or may have greater motoror sensory function on one side ofthe body. Incomplete SCIs fall intoseveral categories. (See Types of in-complete SCIs.

Clinical evaluationSigns and symptoms of SCI include:• extreme pain or pressure in the

neck, head, or back • tingling or sensation loss in the

hands, fingers, feet, or toes • partial or complete loss of con-

trol over any body part • urinary or bowel urgency, incon-

tinence, or retention • difficulty with balance and walking • impaired breathing• abnormal bandlike sensations in

the thorax, with pain and pressure • unusual lumps on the head or

spine.SCI may be ruled out by check-

ing for criteria from the NationalEmergency X-Radiography Utiliza-tion Study. (See NEXUS criteria toexclude SCI.)

Patients with a suspected SCImust undergo a thorough examina-tion using a validated assessmenttool, such as the International Stan-dards for Neurological Classificationof Spinal Cord Injury from theAmerican Spinal Injury Association(ASIA) examination. This tool pro-motes appropriate evaluation ofmotor and sensory function andclassifies the degree of impairmentas complete (type A) or incomplete(types B through E). To learn more about ASIA and access its re-sources, visit asia-spinalinjury.organd elearnsci.org.

Radiologic evaluationBest practices for SCI evaluation in-clude use of computerized tomogra-phy (CT) when available. TheAmerican Association of Neurologi-cal Surgeons/Congress of Neurologi-cal Surgeons 2013 Joint Guidelinesfor the Management of Acute Cervi-cal Spine and Spinal Cord Injuryrecommend traditional X-rays onlyif high-quality CT isn’t available. Forpatients with known or suspectedSCIs, magnetic resonance imaginghelps visualizes the spinal cord anddetects ligamentous injury, blood

Caring for patients with spinal cord injuries

Learn how to help stabilize patients and preventcomplications of these devastating injuries.

LEARNING OBJECTIVES1. Differentiate the types of spinal

cord injuries (SCIs).2. Describe the evaluation of pa-

tients with SCIs.3. Discuss treatment of patients with

SCIs.

The authors and planners of this CNE activity havedisclosed no relevant financial relationships withany commercial companies pertaining to thisactivity. See the last page of the article to learnhow to earn CNE credit.

Expiration: 5/1/19

CNE1.55 contact

hours

By Mark Bauman, MS, RN, CCRN, andTammy Russo-McCourt, BSN, RN, CCRN

www.AmericanNurseToday.com May 2016 American Nurse Today 19

clots, and herniated discs or othermasses that may be compressingthe cord. Providers should followtheir facility’s spinal-clearance proto-cols for SCI detection.

TreatmentTreatment begins even before thepatient is admitted. Paramedics orother emergency medical servicespersonnel carefully immobilize thespine at the scene. In the emer-gency department (ED), immobiliza-tion continues while the healthcareteam identifies and addresses moreimmediate life-threatening problems.If the patient needs emergency sur-gery for trauma to the abdomen,chest, or other area, immobilizationand alignment must be maintainedduring the operation.

For many CSI patients, tractionmay be indicated to help bring thespine into proper alignment and re-store blood flow to the injured area.Occasionally, a surgeon may takethe patient to the operating roomimmediately if the cord appears tobe compressed by a herniated disc,blood clot, or other lesion. Thismost often happens with an incom-plete SCI or progressive neurologicdeterioration. Even if surgery can’treverse spinal cord damage, it maybe needed to stabilize the spine toprevent future pain or deformity.

Nursing care Nursing care can prevent or mitigatefurther injury and promote the bestpossible patient outcome. Focusyour care on:• maintaining stable blood pressure

(BP)• monitoring cardiovascular func-

tion• ensuring adequate ventilation

and lung function• preventing and promptly ad-

dressing infection and other com-plications. Use serial SCI assessments with a

consistent grading tool to monitorand communicate motor and senso-ry improvement or deterioration, in-

cluding reflexes, deep tendon func-tion, and rectal tone. Be sure to es-tablish baseline findings and per-form serial assessments—usuallyhourly or more often during the ini-tial injury phase and less often asthe injury stabilizes. Conduct addi-tional assessments and documentfindings each time the patient hasbeen moved out of bed (for in-stance, for diagnostic tests) or if yoususpect deterioration.

Establishing a baseline helpscaregivers promptly detect improve-ment or deterioration. Assessmentshould be interprofessional, involv-ing the provider, nurse, and physi-cal therapist.

Always logroll the patient tocheck for rectal tone as well aswhen repositioning, toileting, andperforming skin care or chest phys-iotherapy (CPT). (See Quick guideto nursing care for SCI patients.)

Respiratory managementRespiratory impairment is the mostcommon complication of acute SCI.The extent of impairment dependson injury level and severity. Take allpossible measures to protect the pa-tient’s airway and maintain ade-quate respiration. High thoracic tocervical SCIs put the patient at riskfor respiratory insufficiency. Lowerspinal injuries have minimal conse-quences for motor function of the

respiratory muscles.Closely monitor the patient’s res-

piratory rate, depth, and pattern,staying alert for paradoxical breath-ing. Also monitor breath sounds,cough strength and effectiveness,gas exchange adequacy, and arterialblood gas (ABG) results. Maintaincontinuous pulse oximetry; whenpossible, use end-tidal capnographyas part of routine monitoring.

Help the patient use incentivespirometry to monitor inspiratorylung volumes. Vital capacity below1 L suggests decreased inspiratorymuscle strength, which may resultin atelectasis and, over time, respi-ratory fatigue and failure. A weak orineffective cough may lead to re-tained secretions and subsequentpneumonia.

As indicated and ordered, provideadjunctive treatments, including CPTand postural drainage, suctioning,bronchoscopy, intrapulmonary per-cussive ventilation (IPV) with aero -solized mucolytics and bronchodila-tors, and mechanical cough assist tohelp mobilize and clear secretions.An abdominal binder placed belowthe costal margin to support the vis-cera can aid breathing by bringingthe diaphragm into a better restingposition.

Intubation. Patients with respira-tory failure require mechanical ven-tilation. If your patient needs intu-

Patients with tetraplegia—a neurologically complete cervical spinal cord injury(SCI)—are at lifelong high risk for secondary medical complications. Pressure ul-cers are the most common complications. In the first year after injury, 15% oftetraplegic patients develop them; incidence rises steadily thereafter. The mostcommon ulcer location is the sacrum. Other complications of tetraplegia includepneumonia and deep vein thrombosis.

Several factors influence mortality in patients with SCI. Perhaps the most sig -nificant is severity of associated injuries. Due to the force needed to fracture thespine, significant damage to the chest or abdomen may accompany SCIs, with po-tentially fatal consequences. In general, younger patients and those with incom-plete SCIs have a better prognosis than older patients and those with tetraplegia.

Respiratory diseases are the leading cause of death in SCI patients, with pneu-monia accounting for 71% of these deaths. The second and third leading causesare heart disease and infections, respectively. The cumulative 20-year survival ratefor SCI patients is 70.6%, but given underreporting and cases lost in follow-up,the actual death rate is probably higher.

Serious and deadly complications of SCI


bation, take care to maintain spinalalignment by using a cervical collar,manual inline traction, or both.

Be sure to initiate the ventilatorbundle for these patients. The Insti-tute for Healthcare Improvement’sventilator bundle includes five com-ponents of care: • at least 30-degree elevation of

the head of the bed• daily sedation interruption and

assessment for readiness to extu-bate

• oral care with chlorhexidine

• peptic ulcer disease prophylaxis • deep vein thrombosis (DVT) pro-

phylaxis. Many patients with injuries at the

C3 vertebral level or higher are ven-tilator dependent. Those with an in-tact phrenic nerve may qualify fordiaphragmatic pacer implantation,which may allow weaning from me-chanical ventilation.

Cardiovascular managementPatients with significant cervical andhigh thoracic injuries (T6 level and

above) may develop neurogenicshock. Caused by loss of sympathet-ic tone, this distributive shock stateresults in vasodilation, profoundbradycardia, and hypothermia. Hy-potension, temperature dysregula-tion, venous stasis, and autonomicdysregulation (AD) may occur.

Hypotension. Hypotension predis-poses the acute SCI patient to a sec-ondary injury from reduced bloodflow and poor spinal cord perfusion,possibly worsening neurologic out-come. Be sure to maintain continu-ous heart rate and BP monitoring.

Expect to manage hypotensionwith volume resuscitation and vaso-pressor therapy. The goal of therapyis to sustain a mean arterial pressure(MAP) of 85 mm Hg or higher for 7days (an approach called hemody-namic push), which studies suggestmay improve neurologic outcomes.

Once the patient is cleared formobilization, neurogenic orthostatichypotension may occur. Such strate-gies as abdominal binder applica-tion, compression stockings, com-pression wrappings for the lowerextremities, and slow elevation ofthe head of the bed may help re-duce this risk.

In patients whose hypotensionpersists despite these interventions,midodrine, pseudoephedrine, andsalt tablets have been shown tohave some effect, such as increasedheart rate and BP. Small studies sug-gest droxidopa also may raise BP.

Typically, patients adapt to a low-er BP over time; some may experi-ence bradycardia from unopposedvagal flow. Vasopressors that raisethe heart rate may offer some bene-fit during the initial hemodynamicpush. Such medications as enteralalbuterol have been used to increasethe heart rate in patients with per-sistent symptomatic bradycardia.

Stimulation of the vasovagal re-flex may lead to cardiac arrest, re-quiring emergency atropine admin-istration. To help prevent asystoleepisodes, hyperoxygenate the pa-tient before turning or suctioning

An incomplete spinal cord injury (SCI) leaves the patient with some motor or sen-sory function below the injury level. Most incomplete SCIs fall into the followingcategories.

Anterior cord syndrome: The most common incomplete SCI, anterior cord syn-drome usually stems from impact trauma with compressionand ischemia to the motor and sensory pathways in the ante-rior parts of the cord. Although patients may feel gross sensa-tion via intact pathways in the posterior part of the cord, theylose movement and fine sensation.

Brown-Sequard syndrome: This rare disorder results from injury to one side ofthe spinal cord, usually by direct insult to the spine, such as apenetrating injury. The defining characteristic is loss of painand temperature sensation on the side opposite the injury,because these pathways cross to the opposite side shortly af-ter entering the spinal cord. The patient loses movement and

some types of sensation below the injury level on the injured side.

Cauda equina syndrome: This progressive neurologic syndrome results from in-jury to the cauda equina, a bundle of nerve roots arising fromthe end of the spinal cord. It’s marked by lumbar pain, weak-ness or paralysis of the lower extremities (which may be asym-metrical), saddle anesthesia, and bowel and bladder inconti-nence. The most common cause of cauda equina syndrome is

significant disc herniation.

Central cord syndrome: Usually caused by trauma, central cord syndrome islinked to damage to the large nerve fibers that carry informa-tion directly from the cerebral cortex to the cord. Signs andsymptoms may include paralysis and loss of fine control ofarm and hand movements, with far less impairment of legmovement. Sensory loss below the SCI site and loss of bladder

control also may occur.

Conus medullaris syndrome: This condition stems from injury to the conusmedullaris, the terminal end of the spinal cord. Patients typi-cally present with sudden onset of lower back pain, bowel andbladder dysfunction, and symmetrical motor and sensory dys-function. Distinguishing this syndrome from cauda equinasyndrome may be difficult.

Images © Tammy Russo-McCourt

Types of incomplete SCIs


(unless contraindicated). Cardiacpacing has been used in patientswhose hypotension fails to resolveover time or who require frequentdoses of anticholinergic drugs.

Temperature dysregulation. Inabil-ity to sweat or shiver (poikilother-mia) affects the patient’s temperatureregulation and can worsen bradycar-dia. Poikilothermia is more likely tooccur with higher-level SCIs andmore complete motor impairment.Monitor environmental temperature,as this can affect body temperature.Hypothermia may worsen bradycar-dia and hypotension. Provide gentlerewarming and monitor core tem-perature continuously.

Venous stasis. DVT and subse-quent venous thromboembolism areserious threats. In SCI, loss of vascu-lar and muscle tone causes venousstasis. Coupled with immobility andinitiation of the clotting cascade(caused by trauma), venous stasisputs patients at high risk for bloodclots—a risk that remains high forup to 3 months after the injury.

Venous stasis prophylaxis in-cludes immediate application ofpneumatic compression sleeves,along with subtherapeutic heparinor enoxaparin initiated 72 hours af-ter the injury, once the bleeding riskresolves. In cases of blood clot for-mation, the patient may receive animplantable filter in addition to con-ventional anticoagulant therapy.

AD. This condition may arisewhen spinal shock starts to resolveand reflexes return. A stimulus (typ-ically a noxious one) activates thespinal reflex mechanism, causingvasoconstriction below the injurylevel, which in turn causes BP torise. Injuries at the T6 level andhigher involve the splanchnic vascu-lar bed, resulting in a “visceralsqueeze,” which further increasesBP and boosts venous return to theheart. Baroreceptors in the carotidarteries and aortic arch detect thecritical rise in BP and send signalsto the brainstem, which respondsby sending messages via the

parasympathetic nervous system toinduce vasodilation and slow theheart rate. Unfortunately, those mes-sages can’t descend below the in-jury level to disrupt vasoconstric-tion. As a result, pallor developsbelow the injury level while flush-ing, sweating, and poundingheadache occur above it.

Many patients with higher-levelSCIs have a lower baseline BP. Ifthey have what’s commonly definedas a “normal” BP, this actually mayrepresent early AD. In some cases,elevated BP reaches levels of clini-cal emergency. Use rapid interven-tions, such as sitting the patient upright to induce orthostasis (if pos-sible) and administering fast-actingantihypertensive agents (such asnifedipine) if ordered, to lower BPas the offending stimulus is identi-fied and eliminated. The most com-mon culprits in AD are a full boweland distended bladder.

GI managementAcute GI problems in SCI patientsmay include paralytic ileus with as-sociated abdominal distention, gas-tric ulcers, and constipation. While

the exact mechanism is unclear,some experts believe ileus stemsfrom loss of balance betweenbranches of the autonomic nervoussystem. Ileus typically resolveswithin the first week after injury.

Monitor the patient’s bowelsounds and abdominal distention atleast every 4 hours. If indicated andordered, insert a decompressivegastric tube to reduce aspiration riskand restore diaphragm position andlung size to normal.

The injury level determines whe -th er the patient has a neurogenic(upper motor neuron) or aneuro-genic (lower motor neuron) bowel. • Neurogenic bowel is marked by

loss of voluntary control of theexternal rectal sphincter, tight re-flexive sphincter tone, retainedstool, and constipation. To aidbowel regulation, the patientmay need a bowel regimen ofstool softeners and a high-fiberdiet along with low-volume ene-mas, glycerin, or bisacodyl sup-positories or digital rectal stimu-lation to cause reflexiveevacuation after the morningmeal. (Gastric distention activates

To rule out cervical spine injury in low-risk patients and eliminate the need forfurther cervical imaging or cervical spine stabilization after blunt trauma, clinicianscan use these criteria from the National Emergency X-Radiography Utilization Group(NEXUS):• no posterior midline cervical spine tenderness • no evidence of intoxication • normal alertness level • no focal neurologic deficit• no painful distracting injury.

NSAID mnemonicTo remember these criteria, you can use the “NSAID” mnemonic below. But keep inmind that “NSAID” refers to absence of NEXUS criteria. Thus, cervical spine injurycan’t be ruled out in a patient who has any of the findings below.

N Neuro deficitS Spinal tenderness (midline)A Altered mental status (normal level of consciousness)I Intoxication (alcohol or drugs)D Distracting injuries

In patients who complain of neck pain, aren’t fully awake, or have obvious weak-ness or other signs or symptoms of neurologic injury, keep the cervical spine in arigid collar until appropriate radiologic studies are completed.

NEXUS criteria to exclude SCI


bowel motility.) To reduce therisk of constipation-induced AD,perform a digital check of therectum for retained stool.

• In aneurogenic bowel, patientshave a slow colonic transporttime and lose both voluntarycontrol and reflexive sphinctertone. Fecal incontinence is com-mon. Stool softeners, mini-ene-mas, and digital stool removalmay keep the rectum empty, re-ducing incontinence frequency.

Genitourinary managementA patient in neurogenic shock expe-riences abrupt loss of voluntarymuscle control and reflexes, result-ing in acute urinary retention. An in-dwelling urinary catheter must be

placed to decompress the bladderand allow close urinary output mon-itoring during the initial resuscitationand critical management phases.The patient may need the catheterfor the duration of the hemodynam-ic push period to prevent bladderdistention and bladder injury. Dur-ing the acute phase, fluid shifts mayresult from I.V. fluid administrationcoupled with use of vasopressors tosupport blood pressure. The cathe -ter stays place until the patientachieves hemodynamic stability, typ-ically defined in intensive care envi-ronments as when the patient nolonger needs vasopressors.

Once this period ends and if thepatient remains stable, restrict fluidsto 2 L/day and follow a straight

catheterization protocol, as ordered.The goal is to achieve a so-calledbalanced bladder, where fluid in-take approximates output. Becauseoverdistention can trigger AD, blad-der volumes typically are targeted to500 mL or less per catheterization.

SCI can cause neurogenic oraneurogenic bladder.• In neurogenic bladder, reflex-ini-

tiated voiding may occur whenthe patient has a full bladder.

• In aneurogenic bladder, suchvoiding doesn’t occur, potentiallycausing overflow urine leakage.Planned intermittent catheteriza-

tion can reduce incontinence. Long-term bladder management varieswith the patient’s bladder type,needs, and lifestyle.

The nursing interventions below can help promote optimal outcomes in patients with spinal cord injury (SCI).

Body system Potential problem Nursing intervention

Respiratory • Respiratory insufficiency, failure, or both • Monitor respirations for signs of fatigue and impending failure. • Provide pulmonary toileting. • Administer bronchodilators, as ordered.

Cardiovascular • Acute hypotension • Maintain mean arterial pressure > 85 mm Hg for first 7 days after injury.

• Bradycardia • Monitor heart rate • Administer medications for symptomatic bradycardia, as ordered.

• Poikilothermia • Maintain normothermia.

• Deep vein thrombosis • Minimize DVT risk. (DVT) • Initiate prophylaxis.

• Orthostatic hypotension • Monitor for orthostatic hypotension.

• Autonomic dysreflexia (AD) • Monitor for signs and symptoms of AD.

Genitourinary • Urinary retention • Decompress bladder via indwelling catheter insertion, as ordered. • Implement intermittent straight catheterization protocol when appropriate.

GI • Ileus • Monitor for abdominal distention.

• Constipation • Maintain bowel elimination.

Musculoskeletal • Contractures • Provide frequent range-of-motion exercises. • Administer antispasmodics, as ordered.

Dermatologic • Skin breakdown • Perform meticulous skin care, frequently observing under splints and braces. • Reposition patient every 2 hours in bed. • Shift weight every 30 minutes when patient is out of bed in upright wheelchair.

Quick guide to nursing care for SCI patients


Musculoskeletal managementPatients with SCIs typically experi-ence muscle spasticity as spinalshock recedes and reflexes return.Spasticity may take a flexor or ex-tensor pattern or a combination.

Spasticity can reduce venouspooling and stabilize the thoracicand abdominal muscles used in res-piration. It’s also associated withchronic pain syndrome, sleep distur-bance, fatigue, joint contracture,bone density loss, heterotopic ossifi-cation (presence of bone in soft tis-sue where it normally doesn’t oc-cur), and skin breakdown.

Nonpharmacologic strategies tomanage spasticity include range-of-motion exercises, positioning tech-niques, weight-bearing exercises,electrical stimulation, and orthosesor splinting to prevent loss of mus-cle length and contractures. Phar-macologic therapy may include ba-clofen, benzodiazepines, alpha2-adrenergic agonists, and regional bot-ulism toxin or phenol injection. Insevere cases, surgical options (whichare irreversible) may be used.

Dermatologic managementA lifelong complication of SCI, pres-sure ulcers may threaten not onlyquality of life but also life itself.Many factors contribute to tissuebreakdown and eventual pressureulcers, including low BP, immobili-ty, friction and shearing forces, un-relieved pressure, moisture, poornutrition, and nonadherence withpreventive strategies.

Prevention and early detectionare the cornerstones of pressure-ulcer management. Routinely inspectthe patient’s skin and use an estab-lished skin risk assessment tool,such as the Braden scale. To ad-dress identified risk factors, developa plan of care. Risk-reduction inter-ventions include:• turning the patient every 2 hours

or more (depending on risk as-sessment findings)

• avoiding positioning the patienton bony prominences, such as

the trochanters, sacrum, andheels

• using specialized support surfaces• minimizing moisture• frequently inspecting the skin un-

der braces and splints• using a custom-fit wheelchair

with pressure-relieving cushions• establishing a pressure-release

regimen (manual or automated)for wheelchair sitting

• providing nutritional counselingand patient education. If skin breakdown occurs, con-

sult specialized wound care servicesfor wound assessment and treat-ment. Treatment options may in-

clude both surgical and nonsurgicalinterventions, depending on woundstage, location, and depth.

Neurologic improvementRecovery of function depends onseverity of the initial injury. Unfortu-nately, patients with a complete SCIare unlikely to regain function be-low the injury level. If some degreeof improvement occurs, it usuallymanifests within the first few daysafter injury.

Incomplete SCIs usually improvesomewhat over time, but this varieswith the specific injury. Althoughfull recovery is rare, some patientsmay be able to improve enough toambulate and control their boweland bladder functions.

Supportive and rehabilitativecare and treatmentOnce the patient is medically stable,care and treatment shift to supportand rehabilitation. Family members,nurses, or specially trained aides mayprovide care, helping the patient

bathe, dress, change position, andperform other activities of daily living.

The profound, life-changing im-plications of SCI for both the patientand family warrant psychosocial,emotional, and vocational support.Before discharge, provide consultsfor physical and occupational thera-py, social work, pastoral care, andfinancial counseling. Inform the pa-tient and family about availablecommunity resources, such as SCIsupport or advocacy groups.

Preventing SCIsWhile recent advances in emergencycare and rehabilitation have in-creased survivability after SCI, ap-proaches for reducing injury extentand restoring function remain limit-ed. No cure for SCI exists, but ongo-ing research to test surgical and drugtherapies continues to progress. Inclinical trials, researchers are explor-ing drug treatments, decompressionsurgery, nerve cell transplantation,nerve regeneration, stem cell thera-py, and complex drug therapies asways to overcome SCI effects.

With no cure for SCI available,prevention remains key. To helpprevent behavior that can lead tothis devastating injury, educate thepublic on how to prevent SCIs. Cau-tion them to always wear seatbeltswhen in motor vehicles, drive sober,prevent falls by securing rugs andcords, use appropriate safety equip-ment during sports (such as helmetswhen cycling, skateboarding, orhorseback riding), and avoid divingin water less than 9' deep or if theycan’t see the bottom of murky water.

An SCI can affect every aspect oflife. But with treatment and rehabili-tation, many patients can lead pro-ductive, independent lives.

Mark Bauman is a clinical educator at the Universityof Maryland Medical Center Midtown Campus inBaltimore. Tammy Russo-McCourt is a senior clinicalnurse at the University of Maryland R Adams CowleyShock Trauma Center in Baltimore.

Visit www.AmericanNurseToday.com/?p=22892 for a list of selected references.

Recovery of functiondepends on severity

of the initial injury.


Please mark the correct answer online.

1. Significant disc herniation is the mostcommon cause of which type of incompletespinal cord injury (SCI)?

a. Anterior cord syndromeb. Brown-Sequard syndromec. Cauda equina syndromed. Central cord syndrome

2. The most common type of incompleteSCI is:

a. anterior cord syndrome.b. Brown-Sequard syndrome.c. cauda equina syndrome.d. central cord syndrome.

3. Loss of pain and temperature sensationon the side opposite the injury is the definingfeature of which type of incomplete SCI?

a. Anterior cord syndromeb. Brown-Sequard syndromec. Cauda equina syndromed. Central cord syndrome

4. Which sign or symptom might eliminatethe need for further cervical imaging orcervical spine stabilization in a low-risk patientwith cervical spine injury after blunt trauma?

a. Weak hand gripb. Lumbar spinal tendernessc. No posterior midline cervical spine

tenderness d. Unsteady gait when walking

5. Which statement related to radiologicevaluation of patients with possible SCI iscorrect?

a. Magnetic resonance imaging is nothelpful in detecting ligamentous injurythat may be compressing the cord.

b. Magnetic resonance imaging does notprovide valuable analysis of the spinalcord.

c. Computerized tomography (CT) andtraditional X-rays are equally acceptable.

d. Traditional X-rays should be used only ifhigh-quality CT isn’t available.

6. Which statement about avoidingrespiratory complications in patients withSCI is accurate?

a. An abdominal binder placed below thecostal margin to support the viscera canaid breathing.

b. An abdominal binder placed above thecostal margin to support the viscera canaid breathing.

c. Vital capacity above 1.5 L suggestsdecreased inspiratory muscle strength.

d. Vital capacity above 2 L suggestsdecreased inspiratory muscle strength.

7. One component of the Institute for Health -care Improvement’s ventilator bundle is:

a. avoiding prophylaxis for peptic ulcerdisease.

b. weekly sedation interruption to assessreadiness to extubate.

c. at least 15-degree elevation of the headof the bed.

d. oral care with chlorhexidine.

8. A sign that might indicate a patient withSCI may be in neurogenic shock is:

a. hyperthermia. b. hypothermia.c. heart rate of 70 beats/minute. d. heart rate of 100 beats/minute.

9. In SCI patients with hypotension, thegoal is to sustain a mean arterial pressure of:

a. 60 mm Hg or higher for 3 days.b. 70 mm Hg or higher for 5 days.c. 85 mm Hg or higher for 7 days.d. 90 mm Hg or higher for 10 days.

10. The most common complication of SCI is: a. respiratory impairment.b. hypertension.c. sympathetic dysregulation.d. paralytic ileus.

11. Which statement about autonomicdysregulation is correct?

a. Treatment includes slow-actingantihypertensive agents.

b. The most common cause is increasedurine output.

c. Injuries at the T2 level and higher involvethe splanchnic vascular bed, which leadsto increased blood pressure (BP).

d. A stimulus activates the spinal reflexmechanism, causing vasoconstriction be-low the injury level, which in turn raises BP.

12. Which statement about patients withaneurogenic bowel is true?

a. They lose both voluntary control andreflexive sphincter tone.

b. They have tight reflexive sphincter toneand retained stool.

c. They may need a bowel regimen of stoolsofteners.

d. They require a digital check of therectum for retained stool.

13. Which statement about genitourinarymanagement of SCI patients is correct?

a. Once the acute phase ends and thepatient is stable, restrict fluids to 1 L/day.

b. Bladder volumes typically are targeted to500 mL or less per catheterization.

c. In aneurogenic bladder, reflex-initiatedvoiding may occur when the patient hasa full bladder.

d. Planned intermittent catheterizationdoes not help reduce incontinence.

14. Strategies for managing spasticity inpatients with SCIs include:

a. avoiding weight-bearing exercises.b. opioid pharmacologic agents.c. orthotics to reduce muscle length.d. electrical stimulation.

15. To help patients avoid skin breakdown,the nurse should:

a. reposition the patient in bed at leastevery 4 hours.

b. shift the patient’s weight every 60minutes when the patient is out of bedin a wheelchair.

c. shift the patient’s weight every 30minutes when the patient is out of bedin a wheelchair.

d. reposition the patient in bed at leastevery 3 hours.

POST-TEST • Caring for patients with spinal cord injuries Earn contact hour credit online at http://www.americannursetoday.com/continuing-education/

Provider accreditationThe American Nurses Association’s Center for Continuing Edu-cation and Professional Development is accredited as aprovider of continuing nursing education by the AmericanNurses Credentialing Center’s Commission on Accreditation.ANCC Provider Number 0023.

Contact hours: 1.55

ANA’s Center for Continuing Education and Professional Devel-opment is approved by the California Board of Registered Nurs-ing, Provider Number CEP6178 for 1.86 contact hours.

Post-test passing score is 80%. Expiration: 5/1/19

ANA Center for Continuing Education and Professional Devel-opment’s accredited provider status refers only to CNE activi-ties and does not imply that there is real or implied endorse-ment of any product, service, or company referred to in thisactivity nor of any company subsidizing costs related to the activity. The author and planners of this CNE activity have dis-closed no relevant financial relationships with any commercialcompanies pertaining to this CNE. See the banner at the top ofthis page to learn how to earn CNE credit.

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